Clinical outcome of double valve repalcement with or without small aortic prosthesis

To determine the effect of aortic prosthesis size on clinical outcome of patients undergoing double cardiac valve replacement [DVR]. A quasi-experimental study. Cardiac Surgery Department, Punjab Institute of Cardiology, Lahore, Pakistan, from February 1996 to December 2008. One hundred and forty patients undergoing double cardiac valve replacement were divided into 2 groups. Group I, 75 [53.6%] receiving aortic prosthesis size of /= 21 mm size. All patients were prospectively followed-up for 12 years in order to study mortality and valve related complications. There were 94 males [67.1%] and 46 females [32.9%] with a mean age of 25.5 +/- 10 years. In Group I, 21 patients [28%] had aortic valve replacement [AVR] with 19 mm valve size and 54 patients [72%] had 21 mm size valves implanted. In Group II, 39 patients [60%] had AVR with 23 mm size valves implanted followed by 16 [24.6%] who received 25 mm size valves. Posterior mitral leaflet was preserved in 15 patients [20%] in Group I and 14 [21.5%] in Group II. Mortality was seen in 13 patients [9.3%]; of these 5 [3.6%] were in Group I and 8 [5.7%] were in Group II. Nine patients [6.4%] had incomplete follow-up [In Group I, 2 patients died in ICU, 2 died within 30 days of admission and one was a late death. In Group II, 1 patient died in ICU, 1 within 30 days of admission and 6 within 1 year of operation]. Double valve replacement with implantation of small aortic prosthesis has similar overall mortality as compared to patients having larger sized aortic valves

Outcome of double vs. single valve replacement for rheumatic heart disease

To compare the follow-up results of double valve replacement [DVR] i.e. mitral valve replacement [MVR] and aortic valve replacement [AVR] vs. isolated MVR or AVR for rheumatic heart disease. An interventional qausi-experimental study. Department of Cardiac Surgery, Punjab Institute of Cardiology, Lahore, from September 1994 till December 2007. Prospective follow-up of 493 patients with mechanical heart valves was carried out using clinical assessment, international normalized ratio and echocardiography. Patients were divided into three groups: group I having MVR, group II having AVR and group III having DVR. Survival, time and causes of mortality, and frequency of valve thrombosis, haemorrhage and cerebrovascular haemorrhage was noted in the three groups and described as proportions. Actuarial survival was analyzed by Kaplan-Meier method. There were 493 with 287 [58.3%] in group I, 87 [17.6%] in group II and 119 [24.1%] in group III. Total follow-up was 2429.2 patient [pt]-years. Of 77 [15.6%] deaths, 19 [3.8%] were in-hospital and 58 [11.8%] were late. In-hospital mortality was highest 4 [4.6%] in group II followed by 5 [4.2%] group III and 10 [3.5%] group I. Late deaths were 39 [13.4%] in group I, 9 [10.2%] in group II and 10 [8.3%] in group III. The total actuarial survival was 84.4% with survival of 83%, 85.1%, 87.4% in groups I, II and III respectively. On follow-up valve thrombosis occurred in 12 [0.49%/pt-years] patients; 9 [0.67%/pt-years] group I, 1 [0.22%/pt-years] in group II and 2 [0.31%/pt-years] in group III. Severe haemorrhage occurred in 19 [0.78%/pt-years]; 14 in [1.04%/pt-years] in group I, 3 [0.66%/pt-years] group II and 2 [0.31%/pt-years] in group III. Cerebrovascular accidents occurred in 34 [1.3%/pt-years]; 26 [1.95%/pt-years] in group I and 4 in groups II [0.89%/pt-years] and III [0.62%/pt-years] each. In patients with rheumatic heart disease having combined mitral and aortic valve disease DVR should be performed whenever indicated as it has similar in-hospital mortality and better late survival as compared to isolated aortic or mitral valve replacement

Biatrial myxoma and atrial septal defect

Myxomas are rarely associated with congenital cardiac anomalies. We report a case of a young female presenting with symptoms of atrial myxoma but having co-existing ASD visualized on 64 slice multidetector computed tomography [MDCT] prior to cardiac surgery. Patient had a successful resection of biatrial myxoma and ASD repair. This case is unique as the myxoma originated from the inferior margin of the ASD straddling the inferior limbus. Over the years due to the left to right shunt at the ASD, the myxoma was initially prolapsing and oscillating between the two atria. As it grew larger it obliterated the ASD and got stuck in the right atrium [RA] and continued to grow giving false impression of a right atrial mass. Multi detector computed tomography is an alternative diagnostic modality to the gold standard transesophageal echo-cardiograph for detection of an ASD in the presence of atrial myxoma. Biatrial myxoma with associated atrial septal defect has optimal postoperative results

In hospital outcome of patients undergoing coronary endarterectomy: comparison between off-pump vs on pump CABG

Due to advancement of non-surgical methods of coronary revascularization the patients referred for surgery have extensive and complex coronary anatomy. Patients with diffuse atheromatous coronary artery disease required coronary artery reconstruction or coronary endarterectomy [CE]. Coronary endarterectomy on beating heart needs skill and better surgical technique. Coronary endarterectomy along with coronary artery bypass grafting [CABG] done on beating heart is compared with coronary endarterectomy done by using conventional CABG technique. Seven hundred and ninety five consecutive patients underwent CABG from January 2006 to March 2007 in a prospective randomized trial at cardiac surgery department, Punjab Institute of Cardiology, Lahore; out of these 115 patients underwent coronary endarterectomy [CE] and were included in this study. Coronary artery bypass grafting was performed in 115 patients. Seventy two [62.6%] were in group A on-pump and 43 [37.39%] were in group B off-pump. Mean age in group A was 55.68 +/- 1.06 and 52.63 +/- 1.40 in group B. Sixty six male and 6 female were included in group A, 40 male and 3 female patients were in group B. In-hospital mortality among patients undergoing CABG was 5.6% in on-pump group and 2.3% in offpump group [p=0.649], the duration of post-operative mechanical ventilation in on-pump was 6.78 +/- 9.34 hours and 5 +/- 4.0 hours in off-pump group [p=0.060], 66.7% patients in on-pump and 58.1% patients in off-pump group required blood transfusions, Intra-aortic balloon pump [IABP] was required in 5.6% of the patients in on-pump group. Other factors included, smoking 26.4% in on-pump and 41.9% in offpump group [p=0.01], Intensive care unit [ICU] stay was statistically significant 4 +/- 3 in on-pump group and 4 +/- 2 in off-pump group [p=0.02], and drain in on-pump group was 455 +/- 208 ml and 540 +/- 370 ml in off-pump group [p=0.01]. Coronary endarterectomy [CE] has higher post-operative morbidity and mortality but the post-operative outcome after the procedure on either technique is comparable and CE is feasible on off-pump technique as well

Early vascular complications of intraaortic balloon counterpulsation in patients undergoing open heart surgery

The use of IABP is helpful for haemodynamic stability of patients with low cardiac output and compromised left ventricular function in patients who undergo coronary artery bypass grafting. This procedure is also associated with some vascular complications due to the insertion of IABP. The objective of this research was to study the vascular complications in patients with IABP counterpulsation. We observed the clinical outcome of these patients with special reference to post IABP complications in our research. One hundred and six consecutive patients were included in this study from August 2005 to February 2007. Mean age of patients was 58.08 +/- 1.814 years. Seventy nine patients [74.5%] were male and 29 [25.5%] were females. Out of these 106 patients, 101 were operated for CABG, one for angina due to aortic stenosis, two patients had ischemic mitral regurgitation and one patient had post infarct VSD. In 102 [96.2%] patients IABP was inserted percutaneously, one patient received transthoracic and in three patients IABP was inserted with open technique. Thirteen [12.3%] patients received IABP with sheath and 93 [87.7%] received IABP without sheath. Ten patients [9.4%] out of 106 developed vascular complications due to insertion of IABP. Seven patients [6.6%] had the major complications and 3 [2.8%] patients developed minor vascular complications. Mortality due to vascular complications in 106 patients was 8.49% with p<0.005. IABP has remarkable beneficial effects in patients with haemodynamic instability due to myocardial ischemia and low cardiac output syndrome. At the same time IABP is related to significant morbidity and mortality related to vascular complications due to its insertion which include limb ischemia, limb loss and even mortality

Mid-term results of endarterectomy in advanced coronary artery disease

To compare the angiographic results of patency of endarterectomized vessels vs non endarterectomized vessels and their associated grafts after one year of coronary artery bypass grafting. Study was conducted at the Cardiology Department, Punjab Institute of Cardiology, Jail Road, Lahore from 1st October 2004 till 30th July 2006. Consecutive patients were included in the study after undergoing coronary artery bypass grafting and coronary endarterectomy in the hospital. All the patients included in the study were followed up prospectively after 1, 3, 6, 9 and 12 months of coronary artery bypass grafting and angiographic studies were performed at the end of 1 year of follow-up. The mean age of the study population was 55.8 +/- 10.1 years. There were 64 [85.3%] males and 11 [14.7%] females. Hypertension and family history of ischemic heart disease both were present in 40 [53.3%] patients. Diabetes mellitus was present in 23 [30.7%] patients while 38 [50.6%] patients were smokers. A total of 266 grafts were applied to these 75 patients. Of these 181 grafts wee applied to non-endarterectomized vessels and 85 to endarterectomized vessels. Follow-up angiography revealed 6 [3.3%] blocked grafts in a total of 181 non endarterectomized vessels. Of the 85 endarterectomized vessels, 4 [4.7%] grafts with their parent vessels were blocked. Graft patency was not significantly different between endarterectomized and non-endarterectomized grafts [95.3% vs 96.6%] p<0.11. All patients receiving LIMA to LAD had patent grafts at the end of one year. The blocked grafts were all SVGs

Early left ventricular remodeling after aortic valve replacement

Aortic valve disease is associated with eccentric or concentric left ventricular [LV] hypertrophy and changes in the LV mass. The relationship between LV mass and function and the effect of LV remodeling after aortic valve replacement [AVR], in patients with aortic valve disease needs evaluation, that is largely unknown in our population. The aim of this study was to evaluate the effect of AVR on LV remodeling, in patients with aortic valve disease. Fifty patients with aortic valve disease were studied using transthoracic echocardiography to assess LV mass before AVR and compared with early postoperative changes in the LV dimensions and function. LV mass was studied preoperatively and before discharge in 50 consecutive patients undergoing isolated aortic valve replacement. Out of fifty patients, 47[94%] were male and 03[6%] were female. Mean age of the patients was 40.42 years. 22 [44%] had isolated aortic stenosis [AS], 16 [32%] patients had isolated aortic regurgitation [AR] and 12 [24%] patients had mixed aortic valve disease [MAVD]. 02 [4%] patients died. LV mass regression was studied in all the patients. In group A, with aortic stenosis, LV regressed to 69.88 gm [mean] with maximum of 156.88 gms and minimum of 0.00 gms [SD 43.67 gms, p value=0.001]. In group B, with aortic regurgitation, LV mass regressed to 203.96 gms [mean] with maximum 453.79 gms and minimum of 45.65 gms [SD 95.33, p value=<0.001]. In group C, with mixed aortic valve disease, postoperatively LV mass regressed to 122.94 gms [mean] with minimum 9.57 and maximum of 224.75 gms [SD 69.53, p value=0.524]. There was significant early LV mass regression after aortic valve replacement in patients with pre existing aortic valve disease. However, it was noticed that LV mass regressed in all patients except no significant changes in LV wall thickness [hypertrophy]

Trans-myocardial revascularization by laser [TMRL] - mechanism of action and five-year follow-up

We report 5 years' follow up of Transmyocardial Revascularization by Laser [TMRL] in patients with Ischemic heart disease and propose a possible mechanism of action of TMRL. Many studies of TMRL on 'no-option' patients have been published reporting symptom relief and improvement in exercise duration, reduction in drugs required and hospitalization for up to one year duration. A Norwegian clinical trial has reported 43 months follow up. Mechanism of action of TMRL is still debatable. We studied 50 patients of Ischemic heart disease NYHA angina class III, IV who were symptomatic on maximum medical treatment, not suited for CABG, PTCA, i.e. 'no-option' patients and were offered TMRL. Their symptoms, exercise tolerance, medications and symptom-free survival were studied for 5 years. A left ventriculogram was performed after 5 years on consenting patients to identify any channels in the myocardium. We offered TMRL to50 patients of angina NYHA class III, IV [mean 3.44 +/- 0.50]. Their angina class improved to mean 1.88 +/- .74 at 6 months [p=0.00585], to 0.96 +/- 0.77 at 2 years [p = .150], and stayed at 2.06 +/- 0.80 at 5 years [p=0.019]. Their ETT mean value before operation was 5.036 +/- 1.54 minutes, at 2 years 6.56 +/- 1.79 minutes [p=7.83 E-18] and at 5 years 5.26 +/- 1.56 minutes [p=0.0002]. Kaplan Meier symptoms free survival rate was 83.1 percent at 6 months 77.3 percent at 2 years and 66.5 percent at 5 years. Left ventriculogram patients showed a meshwork of channels in the lased myocardium. Transmyocardial Revascularization by Laser provides improvement of 1-2 angina classes, quality of life perception as well as in effort tolerance in 'no-option' patients of Ischemic heart disease. The improvement is maintained beyond five years. Lased myocardium develops a network of new vascular channels which originate from left ventricular cavity

Trans-myocardial revascularization by laser, two-year follow-up

The objective of this study was to investigate the effects of Transmyocardial Revascularization by Laser [TMRL] in patients of ischemic heart disease. 50 patients of ischemic heart disease NYHA class III, IV who were not suitable for other methods of revascularization like CABG, PTCA ['No Option' patients] were offered TMRL. These patients were symptomatic on maximum medical treatment. 50 patients of angina NYHA class III, IV [mean 3.44 +/- 0.50] were offered TMRL. Their angina class improved to mean 1.88 +/- 0.74 at 6 month [p=0.00585] and persisted at mean 0.96 +/- 0.77 at 2 years [p =0 0.0150]. Their ETT mean value before operation was 5.036 +/- 1.54 minutes and at 2 years mean was 6.56 +/- 1.79 minutes [p=0.8318]. Kaplan Meier symptoms free survival rate was 83.1% at 6 months [14 censored] and 77.3 at 2 years [24 censored]